Provider First Line Business Practice Location Address: 
4313 STATE ROUTE 51
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROSTRAVER TOWNSHIP
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15012-3535
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
412-564-3210
    Provider Business Practice Location Address Fax Number: 
724-798-4637
    Provider Enumeration Date: 
10/24/2006